1 reviews | Active since Dec 2017
SEVERE WARNING TO GENESIS MEDICAL SCHEME MEMBERS
SEVERE WARNING TO GENESIS MEDICAL SCHEME MEMBERS: SPECIALIST HOSPITAL ADMISSION MAY STILL LEAVE YOU WITH R0 COVER I am posting this as a serious warning to Genesis members on any option, including a comprehensive option with savings. Broader day-to-day benefits or a savings component would not have changed Genesis's use of Annexure C, Rule 31 for my hospital admission. If a fully qualified specialist admits you to a ward for urgent investigation, you may reasonably believe your medical scheme will deal with the hospital cost while you focus on your health. That was not my experience. Following an acute and abnormal neurological episode, together with my cardiac-risk history, my treating medical team admitted me to hospital for urgent EEG monitoring and further investigation. While I was in a ward, Genesis declined the admission authorisation and my claims portal showed R0 benefit amounts against the hospital-related provider claims. Genesis used Annexure C, Rule 31, and quoted the following wording to me: "Unless expressly stated to the contrary or elsewhere in these rules, diagnostic tests and examinations for monitoring purposes, or that do not result in the diagnosis or confirmation of an illness or disease that necessitates surgery." Genesis later said that the admission authorisation would remain declined until it received clinical input from the treating specialist and the hospital. That leaves a fundamental concern: if clinical information was necessary to decide whether the rule should govern this case, why was the admission authorisation declined before that information had been received and assessed by an appropriate clinician? The practical result was that I was dealing with a serious health concern while facing financial exposure, anxiety and a lack of clarity about a declined hospital admission. The hospital and treating doctors were also left having to provide further records after the event so that Genesis could consider reopening the matter. My concern is not that a medical scheme may never ask for clinical information. Of course it may. My concern is the apparent default: a specialist admits a member to hospital; Genesis invokes a diagnostic exclusion; the admission authorisation is declined; and only then does the clinical assessment process begin. This raises a serious question for every Genesis member: if urgent hospital investigation does not lead to surgery, does Genesis regard the admission as excluded—even where it is necessary to diagnose, rule out or manage a possible PMB condition or medical emergency? PMBs are meant to protect members' access to the diagnosis, treatment and care of defined conditions and emergencies. A member should not have to wait for a surgical outcome before receiving clarity on whether necessary hospital investigation will be funded. Genesis is a comparatively small scheme. I expected human engagement, sensible clinical assessment and proper ownership of an exceptional case. Instead, I experienced a declined admission authorisation, R0 benefits shown on the portal, and weeks without a substantive answer. I ask Genesis to complete the assessment urgently, consider the treating specialists' clinical evidence and the PMB considerations raised, and provide a properly reasoned funding decision.
Dear Mr Swart
We acknowledge receipt of your review.
We will engage with our Clinical Department and revert as soon as we have more information.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Swart
We acknowledge receipt of your review.
We will engage with our Clinical Department and revert as soon as we have more information.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Swart
We apologise for the delay in responding to your review. The background to this matter is not entirely straightforward, and we appreciate the opportunity to explain the relevant factors and the reasons behind the Scheme’s decision.
Providing this context is important, as the circumstances you have experienced are not unique to you as a Genesis member. Rather, they reflect a much broader and increasingly significant challenge facing medical schemes and the private healthcare sector as a whole. This issue has, over time, become something of an “elephant in the room” and is having an increasing impact on how medical schemes assess and fund treatment, particularly in relation to what constitutes medically appropriate and clinically necessary care.
We are unable to disclose or discuss your confidential medical information on a public platform. We will, however, do our best to explain the circumstances surrounding your admission and the basis for the Scheme’s decision.
When you were admitted to hospital in August 2026, the symptoms you presented with were considered sufficient to justify further in-hospital investigation. The Scheme therefore accepts that the initial 24-hour EEG monitoring was medically appropriate.
During your admission, however, a number of additional, or seemingly unrelated tests and investigations were also performed, and medication was prescribed or administered that could not be linked to the clinical reason for your admission or to a confirmed diagnosis of an illness that required such medication.
The Scheme made repeated attempts, both during your admission and for more than a month after your discharge, to obtain the relevant clinical information from your treating doctor to support the substantial additional tests and examinations. These requests were not made to avoid paying for your hospital treatment, but to obtain the clinical information necessary to establish the diagnosis, treatment plan and medical necessity for the services being claimed and to confirm that you are indeed entitled to the benefit in terms of the Scheme’s rules.
Unfortunately, the requested clinical information from your treating doctor has still not been provided and as a result, the Scheme does not have sufficient clinical evidence to support the funding of the additional investigations.
Following the initial 24-hour assessment, the condition that had initially been suspected was ruled out. There is also no clinical information indicating that you subsequently received treatment for this condition, or for another condition that could possibly relate to your admission. Furthermore, the hospital was unable to provide any treatment plan.
Medical schemes do not fund investigations, medication or treatment simply because these services were provided during a hospital admission, especially not if there was no definitive diagnosis or corresponding treatment. There must be a reasonable clinical relationship between the services provided and the condition or symptoms for which the patient was admitted, supported by appropriate clinical information and treatment. This principle applies to all members and ensures that Scheme funds are used appropriately and sustainably.
In this instance, the Scheme is satisfied that the initial 24-hour EEG monitoring required for the hospital stay was medically appropriate given the symptoms you presented with. We will therefore fund the appropriate portion of your admission and the EEG investigation. However, in the absence of clinical information establishing the medical necessity of the subsequent, unrelated investigations and medication, the Scheme cannot accept responsibility for funding these additional services.
We trust that this explanation provides a better understanding of the circumstances and the basis for the Scheme’s decision.
Yours sincerely
Dear Mr Swart
We apologise for the delay in responding to your review. The background to this matter is not entirely straightforward, and we appreciate the opportunity to explain the relevant factors and the reasons behind the Scheme’s decision.
Providing this context is important, as the circumstances you have experienced are not unique to you as a Genesis member. Rather, they reflect a much broader and increasingly significant challenge facing medical schemes and the private healthcare sector as a whole. This issue has, over time, become something of an “elephant in the room” and is having an increasing impact on how medical schemes assess and fund treatment, particularly in relation to what constitutes medically appropriate and clinically necessary care.
We are unable to disclose or discuss your confidential medical information on a public platform. We will, however, do our best to explain the circumstances surrounding your admission and the basis for the Scheme’s decision.
When you were admitted to hospital in August 2026, the symptoms you presented with were considered sufficient to justify further in-hospital investigation. The Scheme therefore accepts that the initial 24-hour EEG monitoring was medically appropriate.
During your admission, however, a number of additional, or seemingly unrelated tests and investigations were also performed, and medication was prescribed or administered that could not be linked to the clinical reason for your admission or to a confirmed diagnosis of an illness that required such medication.
The Scheme made repeated attempts, both during your admission and for more than a month after your discharge, to obtain the relevant clinical information from your treating doctor to support the substantial additional tests and examinations. These requests were not made to avoid paying for your hospital treatment, but to obtain the clinical information necessary to establish the diagnosis, treatment plan and medical necessity for the services being claimed and to confirm that you are indeed entitled to the benefit in terms of the Scheme’s rules.
Unfortunately, the requested clinical information from your treating doctor has still not been provided and as a result, the Scheme does not have sufficient clinical evidence to support the funding of the additional investigations.
Following the initial 24-hour assessment, the condition that had initially been suspected was ruled out. There is also no clinical information indicating that you subsequently received treatment for this condition, or for another condition that could possibly relate to your admission. Furthermore, the hospital was unable to provide any treatment plan.
Medical schemes do not fund investigations, medication or treatment simply because these services were provided during a hospital admission, especially not if there was no definitive diagnosis or corresponding treatment. There must be a reasonable clinical relationship between the services provided and the condition or symptoms for which the patient was admitted, supported by appropriate clinical information and treatment. This principle applies to all members and ensures that Scheme funds are used appropriately and sustainably.
In this instance, the Scheme is satisfied that the initial 24-hour EEG monitoring required for the hospital stay was medically appropriate given the symptoms you presented with. We will therefore fund the appropriate portion of your admission and the EEG investigation. However, in the absence of clinical information establishing the medical necessity of the subsequent, unrelated investigations and medication, the Scheme cannot accept responsibility for funding these additional services.
We trust that this explanation provides a better understanding of the circumstances and the basis for the Scheme’s decision.
Yours sincerely
Dear Mr Swart
Our initial response to your review remains relevant, and there is no further information that we can add that would change the position already communicated to you.
To clarify, no new or relevant information has been provided that would demonstrate the clinical appropriateness or medical necessity of the additional pathology tests performed during your admission.
The two pathology tests you specifically refer to, which confirmed pre-diabetes and elevated ferritin levels, were unrelated to the clinical reason for your hospital admission. As you are aware, your admission for the relevant condition was funded by the Scheme. However, the two additional tests in question, irrespective of the conditions they may have identified, could have been performed on an outpatient basis and were not related to the treatment or management of the condition for which you were admitted to hospital.
By way of example, consider a member who is admitted to hospital for the treatment of pneumonia but, during the same admission, undergoes a sleep study. Although the sleep study may identify a separate medical condition, it is not related to the diagnosis or treatment of the pneumonia. The sleep study would therefore not be considered part of the clinically necessary treatment associated with that admission, and the associated cost would be for the member’s own account.
The same principle applies to the pathology tests in question. The fact that tests were performed while you were in hospital does not, in itself, mean that they are automatically eligible for funding by the Scheme. Medical schemes assess claims in accordance with the clinical relevance and medical necessity of the services provided in relation to the condition being treated.
As explained in our previous response, the situation you have experienced, where certain claims were funded and others were not, is not unique to Genesis members. It reflects a broader and increasingly significant challenge within the medical schemes and private healthcare environment regarding the appropriate use and funding of healthcare services.
It is important to distinguish between services that are clinically necessary and related to the condition for which a member is admitted, and additional investigations that may identify or assess unrelated conditions. Medical schemes are not required to fund every investigation or test performed during a hospital admission simply because the member is an inpatient at the time. Funding is based on the clinical appropriateness and relevance of the services to the condition being treated.
Where additional investigations are performed to investigate or identify conditions unrelated to the reason for admission, and where those investigations could appropriately have been performed outside of the hospital admission, the associated costs may not be funded by the Scheme and may therefore be for the member’s own account.
We trust that this explanation provides further clarity regarding the reasons why the pathology claims in question were not funded by the Scheme.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Swart
Our initial response to your review remains relevant, and there is no further information that we can add that would change the position already communicated to you.
To clarify, no new or relevant information has been provided that would demonstrate the clinical appropriateness or medical necessity of the additional pathology tests performed during your admission.
The two pathology tests you specifically refer to, which confirmed pre-diabetes and elevated ferritin levels, were unrelated to the clinical reason for your hospital admission. As you are aware, your admission for the relevant condition was funded by the Scheme. However, the two additional tests in question, irrespective of the conditions they may have identified, could have been performed on an outpatient basis and were not related to the treatment or management of the condition for which you were admitted to hospital.
By way of example, consider a member who is admitted to hospital for the treatment of pneumonia but, during the same admission, undergoes a sleep study. Although the sleep study may identify a separate medical condition, it is not related to the diagnosis or treatment of the pneumonia. The sleep study would therefore not be considered part of the clinically necessary treatment associated with that admission, and the associated cost would be for the member’s own account.
The same principle applies to the pathology tests in question. The fact that tests were performed while you were in hospital does not, in itself, mean that they are automatically eligible for funding by the Scheme. Medical schemes assess claims in accordance with the clinical relevance and medical necessity of the services provided in relation to the condition being treated.
As explained in our previous response, the situation you have experienced, where certain claims were funded and others were not, is not unique to Genesis members. It reflects a broader and increasingly significant challenge within the medical schemes and private healthcare environment regarding the appropriate use and funding of healthcare services.
It is important to distinguish between services that are clinically necessary and related to the condition for which a member is admitted, and additional investigations that may identify or assess unrelated conditions. Medical schemes are not required to fund every investigation or test performed during a hospital admission simply because the member is an inpatient at the time. Funding is based on the clinical appropriateness and relevance of the services to the condition being treated.
Where additional investigations are performed to investigate or identify conditions unrelated to the reason for admission, and where those investigations could appropriately have been performed outside of the hospital admission, the associated costs may not be funded by the Scheme and may therefore be for the member’s own account.
We trust that this explanation provides further clarity regarding the reasons why the pathology claims in question were not funded by the Scheme.
Yours sincerely
GENESIS MEDICAL SCHEME